Abstract Number: Esoc2026a866 Adjunctive Intra-Arterial Alteplase After Endovascular Reperfusion Versus Direct Endovascular Thrombectomy in Patients Without Intravenous Thrombolysis: A Subgroup Analysis of the Pearl Trial

Abstract Background and aims We aimed to evaluate the efficacy of adjunctive intra-arterial alteplase after endovascular reperfusion in acute ischemic patients without intravenous thrombolysis. Methods This is a post hoc analysis of the intra-arterial alteplase after successful endovascular reperfusion in acute stroke trial (PEARL, NCT05856851). From 324 randomized patients in the PEARL trial, 189 patients without intravenous thrombolysis were included in this post hoc subgroup analysis. The primary outcome was the proportion of patients with a modified Rankin Scale score (mRS) of 0 or 1 at 90 days. The safety outcomes included symptomatic intracranial hemorrhage (sICH) within 36 hours, any intracranial hemorrhage (ICH) within 36 hours, and all-cause mortality within 90 days. Results Of the 189 patients, 95 were assigned to intra-arterial alteplase group and 94 to the standard treatment group. The proportion of patients with a mRS of 0 or 1 at 90 days was 43.2% in the intra-arterial alteplase group vs 22.6% in the standard treatment group (adjusted risk ratio RR, 1.86 95% CI, 1.19-2.91; P = 0.007). ICH within 36 hours (32.6% vs 30.9%, adjusted RR, 1.044 95% CI, 0.681-1.6; P = 0.843), sICH within 36 hours (5.3% vs 5.3%, adjusted RR, 0.931 95% CI, 0.277-3.129; P = 0.908), and all-cause mortality within 90 days (adjusted hazard ratio, 0.995 95% CI, 0.487-2.04; P = 1.000) did not show significant difference between the two groups. Conclusions Among acute ischemic stroke patients due to large vessel occlusion who did not receive intravenous thrombolysis, adjunctive intra-arterial alteplase after successful endovascular reperfusion was associated with better functional outcomes at 90 days. Conflict of interest Zhenhong Deng: nothing to disclose. Yanting Chen: nothing to disclose. Xiaoming Rong: nothing to disclose. Jinyuan Wang: nothing to disclose. Mengqi Liu: nothing to disclose. Qianqing Li: nothing to disclose. Xuejing Lin: nothing to disclose. Yaxuan Pi: nothing to disclose. Yongteng Xu: nothing to disclose. Songhua Xiao: nothing to disclose. Xinguang Yang: nothing to disclose. Yamei Tang: nothing to disclose.